Quality and Resource Utilization Report (QRUR): The Value Modifier Report Card

Sharon Phelps, RN, CHTS-CP, CPHIMS

October 25, 2016 (2-3 pm MDT)

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2

Welcome

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presentation. To see more lines of captioned text,

click the small arrow below.

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• Mountain-Pacific Quality Health

– Funded by Centers for Medicare & Medicaid Services

(CMS)

– Quality Innovation Network-Quality Improvement

Organization (QIN-QIO)

– Serves Montana, Wyoming, Alaska and Hawaii

• HTS is a department of Mountain-Pacific

– Has assisted 1480 providers and 50 critical access

hospitals to reach Meaningful Use under CMS EHR

Incentive program

– Assists health care facilities with utilizing health

information technology (HIT) to improve health care,

quality, efficiency and outcomes 4

The presenter is not an attorney and the information provided is the

presenter(s)’ opinion and should not be taken as legal advice. The

information is presented for informational purposes only.

Compliance with regulations can involve legal subject matter with

serious consequences. The information contained in the webinar(s)

and related materials (including, but not limited to, recordings,

handouts, and presentation documents) is not intended to constitute

legal advice or the rendering of legal, consulting or other professional

services of any kind. Users of the webinar(s) and webinar materials

should not in any manner rely upon or construe the information as

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competent legal or other professional before acting, or failing to act,

based upon the information contained in the webinar(s) in order to

ascertain what is may be best for the users individual needs.

Legal Disclaimer

5

6

Introducing Sharon Phelps, RN, Quality

Improvement Specialist, with Mountain-Pacific

Quality Health

Poll Question What method and what mechanism did you use

for reporting PQRS in 2015?

• GPRO – Web Interface

• GPRO – EHR

• GPRO – Registry

• GPRO – QCDR, Qualified Clinical Data Registry

• Individual – Claim

• Individual – EHR

• Individual – Registry

• Individual – QCDR- Qualified Clinical Data Registry

• Through ACO

• Did not report 7

Goals/Agenda

At the end of this session, you will

be able to:

• Briefly describe CMS Incentive and Pay-

for-Performance Programs

• Understand QRUR and supporting

documents

• Understand Quality and Cost components

• Discuss important items to review in QRUR

• Explain Informal Review request process 8

PQRS and Value Modifier Overview

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A Quick Overview • Physician Quality Reporting System (PQRS)

– Started as “incentive” program in 2006, with 2014 being

last year for an incentive

– Currently “all or none” program

– Applied at Tax Identification Number–National Provider

Identifier (TIN-NPI) level

• Value Modifier (VM)

– Budget neutral pay-for-performance program mandated

by Affordable Care Act in 2010

– Uses data submitted under PQRS combined with claims

data

– Affects sub-group of eligible professional (EP) types

– Applied at TIN level 10

PQRS for 2015 Reporting Year

• Successful PQRS reporting on quality

measure performance in 2015 avoids

negative adjustment for PQRS adjustment

in 2017 payment year

• Unsuccessful reporting of quality measures

or failure to report quality measures triggers

automatic negative 2.0% PQRS payment

adjustment on Medicare Part B payments

at TIN-NPI level

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Value Modifier for CY2017 • Applies to all physicians in groups with 2+

eligible professionals (EPs) and to physician

solo practitioners, as identified by Medicare-

enrolled Taxpayer Identification Number (TIN)

• Based on participation in Physician Quality

Reporting System (PQRS) in 2015

• For TINs subject to 2017 VM, QRUR shows how

VM will apply to physician payments under

Medicare PFS for physicians who bill under TIN

in 2017

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/2015-QRUR.html

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How is the Value Modifier

calculated?

The attribution method focuses on the

delivery of primary care services

• Beneficiaries are assigned to provider group where they

received plurality of primary care services from

primary care physicians during the year

• If beneficiary received no primary care services from

primary care provider, he/she is assigned to group

where he/she received plurality of his/her primary care

services from either specialists or non-physician

providers

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Downloads/2016-03-25-Attribution-Fact-

Sheet.pdf

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The QRUR Quality and Resource Utilization Report

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Poll Questions Have you successfully obtained your 2015

Annual QRUR?

• Yes

• No

Were you surprised by the results?

• Yes, we will be filing an informal review

• Yes, we will not be filing an informal review

• No, our results are what we expected, or

we do not believe an informal review will

change our quality tier results 15

QRURs and Feedback Report

• Annual QRUR http://mpqhf.com/blog/hts-pqrs-whats-in-my-qrur/

• MidYear QRUR

• Supplemental Reports https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-

Episode-Grouper.html

• PQRS Feedback Report https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2015_PQRS_FeedbackReportUG.pdf

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What is the 2015 Annual

QRUR? • Shows performance in 2015 at the TIN level

• Shows how VM will apply to physician

payments under Medicare PFS for physicians

who bill under TIN in 2017

• Based on all services provided from:

– January 1, 2015 thru December 31, 2015

• Cost is based on administrative claims data

• Quality is based on:

– Quality measures submitted under PQRS

– 3 claims-based quality outcomes measures from

claims calculated by CMS 17

Who gets a QRUR?

• Provided by CMS to all groups and solo

practitioners nationwide who had at least

one EP bill Medicare-covered services

under TIN in 2015

• TINs that did not have at least one EP bill

Medicare PFS under TIN in 2015 will have

QRUR for informational purposes only, and

Value Modifier will not affect their payments

under Meditech PFS in 2017

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How do I obtain a QRUR?

• In CMS Enterprise Identity Management

System (EIDM) Portal under Physician

Value-Physician Quality (PV-PQRS) section https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Downloads/2015-

QRUR-Guide.pdf

PQRS Feedback Reports and QRURs can be accessed

at https://portal.cms.gov using same EIDM account

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CMS Portal (EIDM)

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EIDM – Feedback Reports

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Finding the QRUR

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Downloading

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The Big Picture Seeing your performance according to CMS

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How to Read QRUR

Step 1

Your TIN’s 2017 Value Modifier

Look at the front page for the big picture

• Adjustment, if applicable, will apply to

payments for all items and services paid

under Medicare PFS for physicians billings

under your TIN in 2017

• 2017 VM does NOT affect payments to other

eligible professional who are NOT physicians

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Front Page - Example #1

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Front Page – Example #2

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How to Read QRUR

Step 2 Look at page 2 next.

• This page shows how Value Modifier will be

applied to TIN in 2017

• Value Modifier is applied based on group size:

– 2 to 9 EPs in group or solo practitioners

– 10 or more EPs in group

• Three adjustment possibilities:

– Upward (positive)

– Neutral (no change)

– Downward (negative)

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VM Payment Adjustment CY2017

"x” refers to a payment adjustment factor yet to be determined

VM is

applied to

solo

physicians

and

physician

groups

depending

upon size.

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The Adjustment Factor (AF)

• Derived from actuarial estimates of

projected billings

• Will determine precise size of reward for

higher performing TINs in a given year

• AF for 2017 Value Modifier will be posted at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/2015-QRUR.html

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Value Modifier (Example #1)

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Exhibit #1 (Example #1)

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2017 Value Modifier Payment

Adjustments under Quality-Tiering (TINs with fewer than 10 EPs)

Low

Quality

Average

Quality

High

Quality

Low Cost 0.0% +1.0 x AF +2.0 x AF

Average

Cost 0.0% 0.0% +1.0 x AF

High Cost 0.0% 0.0% 0.0%

How to Read QRUR

Step 3: The High Risk Bonus (Example #2)

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Exhibit #2 (Example #2)

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2017 Value Modifier Payment

Adjustments under Quality-Tiering (TINs with 10 or more EPs)

Low

Quality

Average

Quality

High

Quality

Low

Cost 0.0% +3.0* x AF +5.0* x AF

Average

Cost -2.0% 0.0% +3.0* x AF

High

Cost -4.0% -2.0% 0.0%

2.0 +1.0 =

+3.0 x AF

Risk Adjustment

How is the cost data risk-adjusted?

• Patient risk is assessed using standard,

CMS risk-adjustment methodology using

Hierarchical Condition Categories

(HCCs)

– Includes pulling diagnosis codes from claims

for up to one year prior to event in question

and determining predicted patient costs based

on those diagnoses

http://mpqhf.com/corporate/wp-content/uploads/2016/08/Quality-Payment-

Program-LAN-8_24_16.pdf

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Quality Component

How to Read QRUR

Step 4

Next, look on page 4, Exhibit 2

• Top line (your TIN’s Quality Composite Score) is

same value we just saw for quality on front page

• Shows how your overall Quality Composite

Score compared to other groups

– Average Quality Composite Score is calculated as

average of measures within each domain that was

reported

37

Your TIN’s Quality Tier

Quality Composite Score

Exhibit 2 will contain indicator of where your

quality performance lands compared to

benchmark for your peer group

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• More than one standard deviation above mean (positive

score) puts you in High Quality category

• More than one standard deviation below mean (negative

score) puts you in Low Quality category

Quality Score Calculation

Quality Measure

Calculations: • Calculated for each domain

for which there is a minimum

number of eligible cases

• Score = average across all

measures

See Exhibit 3

for table for

each domain

to see how

you compared

to benchmark.

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Outcome Quality Measures

Cost Component

42

How to Read QRUR

Step 5

Now look at Exhibit 4

• Similar to Exhibit 2 except cost component of modifier

• Again, Standardized Cost Composite Score goes into modifier on front page; shows how your Average Cost Composite Score compares to your peers

• In this instance… – Negative standardized scores indicate lower

costs (better performance)

– Positive scores indicate higher costs (worse performance) 43

Your TIN’s Cost Tier

Cost Composite Score

Exhibit 4 will contain indicator of where your cost

performance lands compared to benchmark for your peer

group.

44

• More than one standard deviation above mean (positive

score) puts you in High Cost category

• More than one standard deviation below mean (negative

score) puts you in Low Cost category

Cost Score

• Six cost measures are classified into two

cost domains:

– (1) Costs for All Beneficiaries

– (2) Costs for Beneficiaries with Specific

Conditions

• Score for each cost domain is calculated as

equally-weighted average of measure

scores within domain for all measures that

have required minimum number of eligible

cases or episodes

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Cost Measures

Exhibits 5-AAB and 5-BSC show your TIN’s

performance on cost measures, by domain, used to

calculate Cost Composite Score 46

Cost for All Attributed

Beneficiaries

47

Costs for Specific Conditions

48

Supporting Documents Tables, supplemental reports, PQRS feedback reports

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What else is in the QRUR? Table Contents Description

Table 1 Physicians and Non-Physician Eligible Professionals

Identified in Your Medicare-Enrolled Taxpayer Identification Number (TIN), Selected Characteristics

Table 2 Beneficiaries and Hospital Admissions (except Medicare Spending per Beneficiary)

Table 3 Per Capita Costs for All Beneficiaries

Table 4 Per Capita Costs for Selected Conditions

Table 5 Medicare Spending per Beneficiary (MSPB)

Table 6 Shared Savings Program

Table 7 Individual Eligible Professional Performance on the 2015 PQRS Measures 50

Supplemental Reports

• Reports include 4 exhibits and 3 drill down

tables

• 2015 Supplemental QRUR

– Exhibits provide results for sum of all instances

of episodes attributed to group

– Drill down tables provide detailed information

for each instance of episodes attributed to

group

– Appendices provide definitions for key terms

and service categories included in reports

51

PQRS Feedback Reports

• Provide individual EPs and group practice with

final determination on whether or not they met

PQRS criteria to avoid 2017 PQRS negative

payment adjustment

• Provide detailed information about quality data

submitted by provider/group

• Reflect data from Medicare PFS claims with

dates of service January 1, 2015 thru

December 31, 2015 and received by February

26, 2016 52

PQRS Feedback Reports

PQRS Payment Adjustment Feedback

PQRS Payment Adjustment Measure Performance Detail Report

53

PQRS Payment Adjustment

Report

Adjustment Summary Tab 54

PQRS Payment Adjustment

Report

Adjustment Summary Tab – Rightmost columns

PQRS Payment Adjustment

Report

Individual Adjustment Detail tab More columns (outcome, face to face,

cross-cutting, etc.)

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Next Steps

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What to do now? • Obtain your QRUR and supporting

documents

• Review your results and compare quality

data to what you submitted

– Start with PQRS Feedback reports

• Determine if there is a discrepancy

– Call HELP desk

– File informal review

• Review your performance on your quality

measures now! 58

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Help Desks

• QRUR and VM

questions

• Phone: 1-888-734-6433

(option 3)

– Monday thru Friday

– 8 AM to 8 PM Eastern

• Email: pvhelpdesk@cms.hhs.gov

Physician Value

Help Desk

QualityNet

Help Desk

• PQRS and EIDM

questions

• Phone: 1-866-288-8912

– Monday thru Friday

– 8 AM to 8 PM Eastern

• Email: qnetsupport@hcqis.gov

Informal Review - PQRS

Deadline:

November

30, 2016

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Informal Review - VM

Deadline:

November

30, 2016

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/Downloads/2017-VM-IR-Quick-Ref-

Guide.pdf

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Poll Question

How confident are you that you can

access the QRUR?

• Very confident

• Somewhat confident

• I am not sure, I could use more

education.

• I am not at all confident that I will be

able to access the reports. 62

Holy MACRA Yup – now that you’ve just got this all

figured out… it is changing!!

63

What’s the future hold? The Final Rule is here!

Find it at: www.qpp.cms.gov

64

The Quality Payment Program

has two tracks to choose from:

Advanced Alternative

Payment Models (APMs)

If you decide to take part in

an Advanced APM, you may

earn a Medicare incentive

payment for participating in

an innovative payment

model

Merit-based Incentive

Payment System (MIPS)

If you decide to participate

in traditional Medicare, you

may earn a performance-

based payment adjustment

through MIPS.

Questions?

• Sarah Leake

– sleake@mpqhf.org

• Sharon Phelps

– sphelps@mpqhf.org

• Amber Rogers

– arogers@mpqhf.org

• New Mountain-Pacific MACRA-QPP Blog

– Sign up for automatic delivery at:

http://mpqhf.org/blog/

Please complete the

survey to help us

better serve you and

meet your needs!

65

Acronyms • ACO: Accountable Care Organization

• AF: Adjustment Factor

• CAHPS: Consumer Assessment of Healthcare Providers & Systems

• CPC: Comprehensive Primary Care

• EIDM: Enterprise Identity Management

• EP: Eligible Professional

• FFS: Fee-for-Service

• GPRO: Group Practice Reporting Option

• MSPB: Medicare Spending per Beneficiary

• NPI: National Provider Identifier

• PECOS: Provider Enrollment, Chain, and Ownership System

• PFS: Physician Fee Schedule

• PQRS: Physician Quality Reporting System

• QRUR: Quality and Resource Use Report

• TIN: Taxpayer Identification Number

• VM: Value-Based Payment Modifier

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THANK YOU!

This material was developed by Mountain-Pacific Quality Health, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for

Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands,

under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents

presented do not necessarily reflect CMS policy. 11SOW-MPQHF-AS-D1-16-34